When surveyed, many physicians say that they will restrict their scope of practice or stop practicing medicine altogether in response to rising malpractice insurance premiums. However, when push comes to shove, physicians’ responses to the latest liability “crisis” have been much more modest. That’s the conclusion of a new look at Pennsylvania’s experience (free access through May 7) during its malpractice crisis, by the Harvard School of Public Health’s Michelle Mello and coauthors, published yesterday as a Health Affairs Web Exclusive.

Using administrative records from a state-run insurance fund in which most Pennsylvania doctors must participate, Mello and colleagues looked at the behavior of physicians in “high-risk” specialties — practice areas such as obstetrics/gynecology and cardiology for which malpractice premiums tend to be relatively high — over the years from 1993 through 2002. They found that contrary to predictions based on the findings of earlier physician surveys, only a small percentage of these high-risk specialists reduced their scope of practice (for example, by eliminating high-risk procedures) in the crisis period, 1999-2002, when malpractice insurance premiums rose sharply.

On average during the crisis period, fewer than 3 percent of high-risk specialists shifted annually from performing major procedures to minor procedures only (0.7 percent) or no procedures (1.8 percent); 8.2 percent of specialists performing only minor procedures stopped doing any procedures, shifting entirely to evaluation and management. What’s more, the proportion of high-risk specialists who restricted their practices during the crisis period was not statistically different from the proportion who did so during 1993-1998, before premiums spiked; thus, it is unlikely that practice restrictions during the crisis period were a reaction to the change in the malpractice environment.

The number of high-risk specialists who stopped practicing in Pennsylvania entirely during the crisis period was more substantial: On average, 15.5 percent left each year during 1999-2002. However, this percentage was not statistically different from the proportion of high-risk specialists who left the state during the pre-crisis 1993-1998 period, nor was it statistically different from the proportion of physicians in a comparison group of “low-risk” specialties who left the state during the crisis period.

Moreover, taking into account new physicians coming into the state, the overall supply of specialists in high-risk fields did not decrease during the crisis period, except in obstetrics-gynecology. The ranks of Pennsylvania OB/GYNs did dip 8 percent from 1999 to 2002, but “this trend had begun before liability premiums soared, and it did not accelerate noticeably afterward. Further, the total number of physicians delivering babies, including family/general practitioners, did not fall significantly as a proportion of the population during the crisis,” Mello and coauthors write.

In addition to obstetrics/gynecology and cardiology, the high-risk specialties examined by Mello and colleagues included anesthesia, emergency medicine, general internal medicine, neurosurgery, orthopedics, radiology, surgery, and urology. The comparison group of low-risk specialties included allergy, dermatology, geriatrics, infectious disease, neurology, pediatrics, and psychiatry.

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It is clear that none of these researchers have had to live in Pennsylvania through the past 5 years, or else the could have experienced first-hand the lack of access to care that Pennsylvanians are going through. I am sure they have no clue that there is only one hospital in the entire northeast portion of Philadelphia (approximately 30% of city population) that provides Labor and delivery services, and that is also closing its doors this July.

The authors have also clearly (and possibly intentionally) limited the “crises period” till 2002, when everybody in PA knows that the “crisis” is still ongoing. What this study very cleverly avoids is giving the real picture of the aftermath of the so-called crisis period.

I must acknowledge that the authors at least mentioned the most critical elements in their acknowledgement of the study’s limitations. However, focusing on these “limitations” will clearly reveal the major flaws in the authors’ conclusions. I hope they do due diligence and come out with a follow up study addressing the limiting factors that they themselves have listed.

That high risk physicians such as OB/GYNs that left was not significantly different than the period prior to the malpractice may be explained by the difficulty such physicians have actually leaving their practice due to the large tail policies for which they usually are individually responsible. A better measure the impact of the malpractice crisis would probably be a measure of new OB/GYNs, etc. that moved into the state during the malpractice crisis.

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